More work is needed to improve nutritional behaviour in Nepal, where nearly half of children under five are chronically malnourished, experts say.
“Food is more than nutrients and knowledge - it is culture, practice, and what you have been told about your life since you were born,” Ramesh Adhikari, a paediatrics professor at Kathmandu Medical College, told IRIN.
Across the country, childhood malnutrition, which results in stunting (low height-for-age, also known as chronic malnutrition) and other long-term health effects, occurs not because of food insecurity or lack of access to nutritious food, but because of behaviour in households which is preventing nutrients from getting to children, they say.
According to a recent report by the World Food Programme (WFP), the prevalence of undernutrition is high even in the wealthiest households, suggesting that other factors beyond food availability and income are influencing nutrition nationwide.
Misconceptions about the food and eating needs of pregnant women are widespread and varied across Nepal, according to a USAID literature review.
“So many families I work with believe that feeding pregnant wives a lot of food will make delivery difficult, so they even reduce the amount of food once they discover the pregnancy,” explained Keshab Dhakal, a health outreach worker in Nepal’s western Kapil Vastu District.
Mothers attending a nutrition seminar at a health post in rural Rupendehi District in southern Nepal listed yoghurt, pumpkin, and eggs among foods they avoided while pregnant.
Said one mother, who is using complementary vitamin packets distributed by Nepal’s Health Ministry: “This is my third child. For the first two, I didn’t eat many things while pregnant. Now, with this one, I think she will be strong and clever because of the vitamins.”
Gender bias in food distribution
Compounding taboos, maternal malnutrition (and therefore child malnutrition) is sometimes the result of gender-based discrimination in decision-making and food-sharing.
“Women, including mothers, usually eat less well than men. This can lead to inadequate foetal growth, ultimately leading to stunting in children by the age of two,” said Saba Mebrahtu, nutrition chief at the UN Children’s Fund (UNICEF) in Nepal.
Many children eat off the plate of a parent, often the mother. Because of food distribution hierarchies, typically giving the male members of the family food before the females, children who eat from mothers’ plates may have limited access to nutritious food, according to studies cited in the USAID review.
“Nutrition education for mothers and children has to start with men,” said Shanti Acharya, a female community health volunteer in Rupendehi. “It’s men who usually make the decisions regarding what to do with vegetables, for example - to sell them or eat them in the household,” she said, adding that this can mean that nutritious foods grown at home are sold more frequently than they are consumed.
Excessive burden on mothers
Women bear much of the burden for child care and food preparation. While WFP analysis shows remittances from outmigration can improve nutrition in households, especially if the household is female-headed, the absence of men also means an increase in women’s workloads, leaving less time for food preparation.
Recognizing what experts call “unpaid care work” performed by women can balance labour distribution in the household - benefiting children by putting more value on preparing their food.
“If fathers are engaged in caring for their children, they will know more about what to feed their children, and notice when feeding and growing aren’t going as well as they should be,” said Mebrahtu, adding that Nepal’s 2013 draft strategy for infant and young child feeding addresses the beliefs of a range of people who influence the mother, including husbands, in-laws, elders, and community members.
Malnourished children are less successful in school, grow into less productive adults, and develop chronic diseases that can put strains on the medical system according to the World Bank, which also warns that malnutrition is costing poor countries up to 3 percent of their yearly GDP.
“The incentives to feed mothers and children well are clear,” said UNICEF’s Mebrahtu. “It’s just a matter of closing the information gaps and correcting misunderstandings and mistreatment.”